Provider Demographics
NPI:1033197942
Name:KHETARPAL, MINOO (MD)
Entity Type:Individual
Prefix:
First Name:MINOO
Middle Name:
Last Name:KHETARPAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4449 FASHION SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-5217
Mailing Address - Country:US
Mailing Address - Phone:989-790-0007
Mailing Address - Fax:989-790-7547
Practice Address - Street 1:1320 N MICHIGAN AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4751
Practice Address - Country:US
Practice Address - Phone:989-755-5500
Practice Address - Fax:989-755-7860
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066477207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4600280Medicaid
MI4600280Medicaid
MIH08283Medicare UPIN